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Patient Demographic


Emergency Contact

Informed Consent For Facial Acupuncture

Instructions - This is an informed consent document that has been prepared to help your acupuncturist inform you concerning facial acupuncture treatments, the risks involved, and possible alternatives.  Please be advised that this is not a surgical procedure.  It is important that you read this information carefully and completely.  Please initial each page, indicating that you have read the page and sign the consent for facial acupuncture treatments, as proposed by your acupuncturist.

Introduction - An acupuncture facial treatment involves the insertion of acupuncture needles into fine lines and wrinkles on the face and neck in order to reduce the visible signs of aging.  In Oriental medicine, the meridians or pathways of Qi (energy) flow throughout the entire body from the soles of the feet up to the face and head; consequently, a facial acupuncture treatment addresses the entire body constitutionally, and is not merely “cosmetic.”  An acupuncture facial involves the patient in an organic, gradual process, that is customized for each individual.  It is no way analogous to, or a substitute for, a surgical “face lift”.  A treatment session may confine itself solely to facial acupuncture, or it may be used in conjunction with other procedures.


Benefits - Facial acupuncture can increase facial tone, decrease puffiness around the eyes, as well as bring more firmness to sagging skin, enhance the radiance of the complexion, and flesh out sunken areas.  Customarily, fine wrinkles will disappear, and deeper ones be reduced.  As this treatment is not merely confined to the face, but incorporates the entire body and constitutional issues of health.

Contraindications for Treatment:

  • High blood pressure

  • Problems with bleeding or bruising

  • Severe Migraine headaches

  •  Parkinson’s disease

  •  Recent Microdermabrasion

  •  Diabetes mellitus

  •  Cancer

  •  AIDS

  •  Recent laser treatments

  •  Hepatitis

  •  Vertigo

  •  Hemophilia

  •  Botox treatments

  •  Dermal filler (Restylane, Juvederm, Radiesse etc)

  •  Any skin diseases (poison ivy, eczema, hives)

  •  Pregnancy

  •  Cold or flu

  •  Herpes outbreak

  •  Allergic reactions

  •  Extreme stress or tension


Alternative Treatment - Improvement of sagging skin, wrinkles and fatty deposits may be attempted by other treatments or surgery such as a surgical facelift, chemical face peels, or liposuction.  Risk and potential complications are associated with these alternative forms of treatment.

Risks of an Acupuncture Facial - Every procedure involves a certain amount of risk and it is important that you understand the risks involved with an acupuncture facial.  An individual’s choice to undergo an acupuncture facial is based upon the comparison of the risk to potential benefit.  Although the majority of patients do not experience the following complications, you should discuss each of them with your acupuncturist to make sure you understand the risks, potential complications, and consequences of an acupuncture facial.

  • Bleeding - It is possible, though very unusual, that you may have problems with bleeding during an acupuncture facial.  Should post-acupuncture bleeding occur, it will usually only consist of a few drops.  Accumulations of blood under the skin may cause a bruise, or hematoma, which will resolve itself.

  • Infection - Infection is very unusual after an acupuncture facial.  Should an infection occur, additional treatment, including antibiotics, may be necessary.

  • Damage to Deeper Structures - Deeper structures such as blood vessels and muscles are rarely damaged during the course of a facial acupuncture treatment.  If this does occur, the injury may be temporary or permanent.

  • Asymmetry - The human face is normally asymmetrical.  Thus, there can be a variation from one side to the other in the results attained from a facial acupuncture treatment.

  • Bruising And Puffiness - There is a possibility of bruising (hematomas), puffiness, blood, tingling, itching, warmth, pain or other symptoms at the site of the needle.

  • Nerve Injury - Injuries to the motor or sensory nerves rarely result from facial acupuncture treatments.  Nerve injuries may cause temporary or permanent loss of facial movements and feeling.  Such injuries may improve over time.  Injury to sensory nerves of the face, neck and ear regions may cause temporary or more rarely permanent numbness.  Painful nerve scarring is very rare.

  • Needle Shock - Needle shock is a rare complication after an acupuncture facial.

  • Unsatisfactory Result - There is the possibility of a poor result from an acupuncture facial.  You may be disappointed with the results.

  • Allergic Reactions - In rare cases, local allergies to topical preparations have been reported.  Systemic reactions which are more serious may occur to herbs used during an acupuncture facial.  Allergic reactions may require additional treatment.

  • Delayed Healing - Delayed wound healing or wound disruption are a rare complication experienced by patients in the aftermath of an acupuncture facial.  There is a greater risk for smokers, who frequently have dry, sagging skin, which does not heal as readily as that of non-smokers.

  • Long Term Effects - Subsequent alterations in facial appearance may occur as the result of the normal process of aging, weight loss or gain, sun exposure, or other circumstances not related to an acupuncture facial.  An acupuncture facial does not arrest the aging process or produce permanent tightening of the face and neck.  Future facial acupuncture maintenance treatments, or other treatments, may be necessary to maintain the results of an acupuncture facial.

MICRONEEDLING- Microneedling is the insertion of very fine needles into the skin for the purpose of rejuvenating the skin.


  • Accutane within 6 months

  • scleroderma

  • collagen vascular disease

  • cardiac abnormalities

  • rosacea

  • blood clotting problems

  • platelet abnormalities

  • anticoagulation therapy (i.e.: Warfarin)

  • facial cancer (past and present)

  • chemotherapy

  • steroid therapy

  • dermatological diseases affecting the face

  • diabetes and other chronic conditions

  • active bacterial infections

  • fungal infections

  • immune suppression

  • scars less than 6 months old

  • Botox/facial fillers in the past 2-4 weeks.

  • Treatment is not recommended for patients who are pregnant or nursing.

Precautions: keloid or raised scarring, eczema, psoriasis, actinic keratosis, and herpes simplex.


Side Effects Typically Include:

  • Skin may be pink or red and feel warm like mild sunburn, or tight and itchy. All of which typically subsides within 12-48 hrs.

  • Minor flaking or dryness of the skin, with scab formation in rare cases.

  • Crusting, discomfort, bruising and swelling may occur.

  • Pinpoint bleeding.

  • It is possible to have a cold sore flare if you have a history of outbreaks.

  • Freckles may lighten temporarily or permanently disappear in treated areas.

  • Infection is rare but if you see any signs of tender redness or pus notify our office immediately.

  • Hyperpigmentation (darkening of the skin) rarely occurs and usually resolves itself after a month.

  • Permanent scarring is extremely rare.

Health Insurance - Most health insurance companies exclude coverage for an acupuncture facial and/or any complications that might occur from an acupuncture facial.  Please carefully review your health insurance subscriber information pamphlet.


Additional Care Necessary - There are many variable conditions in addition to risk and potential complications that may influence the long term result from acupuncture facial treatments.  Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with an acupuncture facial treatment.  Other complications and risks can occur but are even more uncommon.  Should complications occur, other treatments may be necessary.  The practice of acupuncture is not an exact science.  Although good results are expected, there is no guarantee or warranty, either expressed or implied, on the results that may be obtained.

Financial Responsibilities - The cost of an acupuncture facial involves several charges for the services provided.  The total includes fees charged by your acupuncturist, the cost of acupuncture supplies, and topical preparations.  Depending on whether the cost of your acupuncture facial is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered.

Disclaimer - Informed-consent documents are used to communicate information about the proposed procedure along with disclosure of risks and alternative forms of treatment(s).  The informed consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.  However, informed consent documents should not be considered all-inclusive in defining other methods of care and risks encountered.  Your acupuncturist may provide you with additional or different information which is based upon all the facts in your particular case and the present state of knowledge within the field of acupuncture.  Informed consent documents are not intended to define or serve as the standard of acupuncture.  Standards of acupuncture are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.  It is important that you read the above information carefully and have all of your questions answered before signing the following consent.


                            Consent For Facial Acupuncture Procedure or Treatment

1. I hereby authorize Dr. Liliana Gomez and such assistants as may be selected to perform an acupuncture facial.  I have received the INFORMED CONSENT FOR FACIAL ACUPUNCTURE.

2. I recognize that during the course of the acupuncture facial, unforeseen conditions may necessitate different procedures than those above.  I therefore authorize the above acupuncturist and assistants or designees to perform such other procedures that are in the exercise of his or her professional judgment necessary and desirable.  The authority granted under this paragraph shall include all conditions that require treatment and are not known to my acupuncturist at the time the procedure is begun.

3. I acknowledge that no guarantee has been given by anyone as to the results that may be obtained.

4. I authorize the release of my Social Security number to appropriate agencies for legal reporting and medical device registration, if applicable.

5. It Has Been Explained To Me In A Way That I Understand:


  1. The Above Treatment Or Exposure To Be Undertaken

  2. There May Be Alternative Procedures Or Methods Of Treatment

  3. There Are Risks To The Procedure Or Treatment Proposed

I Consent To The Treatment Or Procedure And The Above Listed Items (1-5).  I Am Satisfied With The Explanation.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

By signing this form, you acknowledge you were advised of the HIPAA Notice of Privacy Practices. Our HIPAA Notice of Privacy Practices provides information about how we may use and disclose your protected information. We encourage you to read it in full. Our Notice of Privacy Practices is subject to change. You may request a copy of the Notice of Privacy.

Financial Policy

Thank you for choosing Holistic Elite as your health care provider. Please carefully read and Initial each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality medical care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you. Please initial below:

1. I understand that if I am unable to make a scheduled appointment, I need to contact Holistic Elite at least 24 hours before my scheduled appointment time. Due to a demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need from being seen. A $35 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELED WITH AT LEAST 24 HOURS ADVANCED NOTICE.

2. I understand that if my accounts not paid in full within 90 days of a statement date, a 35 collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.

I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the attending physician.

Form Submitted!

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